Abdominal Pain And Its Clinical Presentations.

Regarding patients presenting with abdominal pain select an option from the list given below:
A. Myocardial infarction
B. Colorectal cancer
C. Duodenal ulcer
D. Gastric ulcer
E. Biliary colic
F. Ruptured abdominal aortic aneurysm
G. Acute pancreatitis
H. Toxic megacolon
I. Diverticulitis
J. Intestinal obstruction

1. A 65-year-old man with a history of ischemic heart disease presents with sudden onset central abdominal pain radiating to his back. He is clammy and short of breath.

Answer: F. Ruptured abdominal aortic aneurysm

2. A 34-year-old man who drinks 21 units of alcohol per week presents with episodic epigastric pain that is relieved by eating.

Answer: C. Duodenal ulcer

3. A 40-year-old woman with a history of Crohn's disease presents with abdominal pain and distension. She describes constipation for the past 4 days.

Answer: J. Intestinal obstruction

Discussion:
Abdominal pain: 
Characteristic exam question features for conditions causing abdominal pain is briefly described below:

1. Peptic ulcer disease: 

• Duodenal ulcers: more common than gastric ulcers,  epigastric pain relieved by eating 
• Gastric ulcers: epigastric pain worsened by eating 
• Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)

2. Appendicitis:

• Pain initial in the central abdomen before localising to the right iliac fossa 
• Anorexia is common 
• Tachycardia, low-grade pyrexia, 
• Tenderness in RIF 
• Rovsing's sign: more pain in RIF than LIF when palpating LIF

3. Acute pancreatitis:

• Usually due to alcohol or gallstones 
• Severe epigastric pain 
• Vomiting is common 
• Examination may reveal tenderness, ileus and low-grade fever 
• Periumbilical discolouration (Cullen's sign) and flank discolouration (Grey-Turner's sign) is described but rare.

4. Biliary colic:

• Pain in the RUQ radiating to the back and interscapular region, may be following a fatty meal. 
• Slight misnomer as the pain may persist for hours 
• Obstructive jaundice may cause pale stools and dark urine

5. Acute cholecystitis: 

• History of gallstones symptoms
• Continuous RUQ pain 
• Fever, raised inflammatory markers and white cells 
• Murphy's sign positive (arrest of inspiration on palpation of the RUQ)

6. Diverticulitis: 

• Colicky pain typically in the LLQ Fever, 
• raised inflammatory markers and white cells

7. Abdominal aortic aneurysm: 

• Severe central abdominal pain radiating to the back 
• Presentation may be catastrophic (e.g. Sudden collapse) or sub-acute (persistent severe central abdominal pain with developing shock) 
• Patients may have a history of cardiovascular disease

8. Intestinal obstruction:

• History of malignancy/previous operations 
• Vomiting 
• Not opened bowels recently 
• 'Tinkling' bowel sounds

Unusual causes of abdominal pain should also be remembered: 

 myocardial infarction 

 diabetic ketoacidosis 

 pneumonia 

 acute intermittent porphyria 

 lead poisoning